MEDICARE: DR. SUSAN ELAINE HICKMAN PHD, PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	P0000002807	TN

General Provider Information

NPI Number	:	1174710396
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUSAN ELAINE HICKMAN PHD, PSYD

Provider Business Mailing Address
First Line	:	3212 DAYTON BLVD STE B
Second Line	:
City	:	RED BANK
State	:	TN
Zip	:	37415-5046
Country	:	US
Telephone Number	:	423-508-8200
Fax Number	:

Provider Business Practice Location Address
First Line	:	3212 DAYTON BLVD STE B
Second Line	:
City	:	RED BANK
State	:	TN
Zip	:	37415-5046
Country	:	US
Telephone Number	:	423-508-8200
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/02/2007
Last Update Date	:	12/31/2019

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